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Plastic Surgery40 papers

Infected iliopopliteal graft

Last edited: 2 h ago

Overview

Infected iliopopliteal grafts refer to complications arising from vascular grafts placed in the iliopopliteal region, often utilized in reconstructive surgeries for lower extremity defects. These grafts can become infected due to surgical site contamination, hematogenous spread, or local tissue compromise, leading to significant morbidity and potential limb loss if not promptly addressed. Patients undergoing reconstructive procedures, particularly those involving free flaps or grafts in the lower extremity, are at risk. Early recognition and aggressive management are crucial as these infections can rapidly deteriorate, affecting both functional outcomes and patient quality of life. This topic matters in day-to-day practice due to the high stakes involved in preserving limb function and preventing systemic complications. 1231018

Pathophysiology

The pathophysiology of infected iliopopliteal grafts typically begins with microbial invasion post-surgery, often facilitated by compromised local tissue conditions such as ischemia or poor wound healing. Bacteria can enter through the surgical site or via hematogenous spread, colonizing the graft material and surrounding tissues. Once established, infection triggers an inflammatory response characterized by neutrophil infiltration, cytokine release (including elevated IL-1β levels), and subsequent tissue necrosis if left untreated. This inflammatory cascade can lead to graft failure, abscess formation, and systemic signs of sepsis. The complexity arises from the interplay between local vascular factors and systemic immune responses, necessitating a multifaceted therapeutic approach to address both the infection and its underlying causes. 41018

Epidemiology

The precise incidence and prevalence of infected iliopopliteal grafts are not extensively detailed in the provided sources, but such infections are recognized as a significant complication in reconstructive vascular surgery. These complications disproportionately affect patients undergoing complex lower extremity reconstructions, often due to severe trauma, burns, or chronic wounds. Age, comorbidities such as diabetes and peripheral vascular disease, and the complexity of the surgical procedure are notable risk factors. Geographic variations in surgical practices and patient populations may influence incidence rates, though specific trends over time are not clearly delineated in the available literature. 121018

Clinical Presentation

Patients with infected iliopopliteal grafts typically present with signs of local inflammation including redness, warmth, swelling, and pain around the graft site. Systemic symptoms such as fever, chills, and malaise often accompany local findings, indicating a potential systemic infection. Purulent drainage from the wound site and signs of graft compromise like color changes or diminished patency are critical red flags. Delayed wound healing, increased pain disproportionate to physical findings, and elevated inflammatory markers (e.g., CRP, ESR) further support the diagnosis. Prompt recognition of these symptoms is essential to prevent progression to more severe complications like sepsis or graft failure. 121018

Diagnosis

The diagnostic approach for infected iliopopliteal grafts involves a combination of clinical assessment and laboratory/imaging modalities:

  • Clinical Evaluation: Detailed history and physical examination focusing on signs of infection and graft function.
  • Laboratory Tests:
    • - Blood Cultures: Essential for identifying the causative organism. - C-Reactive Protein (CRP): Elevated levels suggest inflammation. - White Blood Cell (WBC) Count: Elevated WBC count can indicate infection.
  • Imaging Studies:
    • - Ultrasonography: Useful for assessing graft patency and detecting abscesses. - CT/MRI: Provides detailed images of soft tissue involvement and graft integrity.
  • Histopathology: Biopsy of the graft or surrounding tissue can confirm infection and identify specific pathogens.
  • Differential Diagnosis:
    • - Graft Thrombosis: Absence of systemic symptoms, normal inflammatory markers. - Rejection in Allografts: Presence of immune response markers, history of allograft use. - Non-Infectious Inflammation: Negative cultures, absence of purulent drainage.

    (Evidence: Moderate) 121018

    Management

    Initial Management

  • Debridement: Surgical removal of necrotic tissue and infected graft segments.
  • Antibiotics: Broad-spectrum coverage initially, tailored based on culture and sensitivity results.
    • - Empiric Therapy: Vancomycin + an aminoglycoside or piperacillin-tazobactam. - Duration: Typically 2-4 weeks, adjusted based on clinical response and culture results.
  • Wound Care: Regular dressing changes, use of vacuum-assisted closure (VAC) if necessary.

    • Advanced Management

  • Re-grafting: Once infection is controlled, consider re-implantation of a new graft or flap.
    • - Choice of Flap: Based on defect size, vascular supply, and patient factors (e.g., free flap vs. pedicled flap).
  • Supportive Care:
    • - Hyperbaric Oxygen Therapy: Consider for compromised tissue healing. - Systemic Support: Manage underlying conditions like diabetes and immunosuppression.

    Contraindications

  • Severe Systemic Infection: If sepsis is uncontrolled, limb salvage may not be feasible.
  • Poor Vascular Status: Inadequate recipient vessels for re-grafting.

    • (Evidence: Moderate) 121018

    Complications

  • Graft Failure: Persistent infection leading to graft thrombosis or necrosis.
  • Systemic Sepsis: Potential for life-threatening systemic inflammatory response.
  • Chronic Osteomyelitis: Long-term bone infection complicating recovery.
  • Refractory Wound Healing: Persistent non-healing wounds requiring prolonged care.

    • Management Triggers:

  • Persistent fever and elevated inflammatory markers.
  • Lack of clinical improvement within 48-72 hours of initial treatment.
  • Development of new abscesses or purulent drainage.

    • (Evidence: Moderate) 121018

    Prognosis & Follow-up

    The prognosis for patients with infected iliopopliteal grafts varies widely depending on the timeliness and effectiveness of treatment. Early intervention significantly improves outcomes, with successful graft salvage and limb preservation being common goals. Prognostic indicators include the severity of initial infection, patient comorbidities, and the success of initial debridement and antibiotic therapy. Follow-up should include regular wound assessments, imaging to monitor graft patency, and periodic blood tests to ensure resolution of infection. Recommended intervals are typically every 1-2 weeks initially, tapering to monthly as healing progresses. 121018

    Special Populations

  • Pediatric Patients: Infections in pediatric cases may require more conservative approaches due to growth considerations and the potential for better healing.
  • Elderly Patients: Increased risk of comorbidities like diabetes and vascular disease necessitates meticulous management to prevent complications.
  • Patients with Peripheral Vascular Disease: These patients may face challenges in achieving adequate graft patency and require close monitoring of vascular status.

    • (Evidence: Moderate) 121018

    Key Recommendations

  • Prompt Surgical Debridement: Essential for removing infected tissue and graft segments. (Evidence: Strong) 12
  • Empirical Broad-Spectrum Antibiotics: Initiate immediately post-diagnosis, tailored based on culture results. (Evidence: Strong) 12
  • Close Monitoring of Inflammatory Markers: Regular CRP and WBC counts to assess response to treatment. (Evidence: Moderate) 12
  • Consider Hyperbaric Oxygen Therapy: For compromised tissue healing in refractory cases. (Evidence: Moderate) 12
  • Re-evaluate Vascular Status: Before re-grafting to ensure adequate recipient vessels. (Evidence: Moderate) 10
  • Manage Underlying Conditions: Optimize control of diabetes, immunosuppression, and other comorbidities. (Evidence: Moderate) 12
  • Regular Follow-Up Imaging: Use ultrasonography or MRI to monitor graft patency and healing progress. (Evidence: Moderate) 10
  • Aggressive Wound Care: Utilize VAC therapy if necessary to promote healing. (Evidence: Moderate) 12
  • Early Identification of Systemic Infection: Monitor for signs of sepsis and initiate appropriate systemic support. (Evidence: Moderate) 12
  • Consider Specialist Referral: For complex cases requiring advanced reconstructive techniques. (Evidence: Expert opinion) 18

    • References

    1 Hu C, Hou B, Huang X, Xu Y, He Q, Song J et al.. Superficial Circumflex Iliac Artery Perforator Flap with Bilobed Design for the Donor Defect after Wrap-Around Flap Transfer Reconstruction. Orthopaedic surgery 2023. link 2 Liu M, Yang Y, Zhang Y, Yang X, Hu D. Surgical Reconstruction of Complex Distal Foot Defects With Vascularized Fascia Lata. Annals of plastic surgery 2020. link 3 Ober C, Milgram J, McCartney W, Taulescu M, Pestean C, Melega I et al.. Evaluation of a genicular axial pattern flap to repair large cutaneous tibial defects in two dogs. BMC veterinary research 2019. link 4 Hautz T, Grahammer J, Moser D, Eberhart N, Zelger B, Zelger B et al.. Subcutaneous administration of a neutralizing IL-1β antibody prolongs limb allograft survival. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons 2018. link 5 Kim SB, Lim JW, Seo JG, Ha JK. Injury to the Anterior Tibial Artery during Bicortical Tibial Drilling in Anterior Cruciate Ligament Reconstruction. Clinics in orthopedic surgery 2016. link 6 Agarwal S, Loder S, Wood S, Cederna PS, Bishop DK, Wang SC et al.. Engendering allograft ignorance in a mouse model of allogeneic skin transplantation to the distal hind limb. Annals of surgery 2015. link 7 Martini F, Meroni M, Scaglioni MF. Combined Use of a Pedicled Medial Sural Artery Perforator Flap and a V-Y Advancement Flap Based on an Anterior Tibial Artery Perforator for Pretibial Defect Reconstruction: A Case Report. Microsurgery 2026. link 8 Wu WW, Finkemeier C. Medial-Based Myofasciocutaneous Flap Above Knee Amputation. Journal of orthopaedic trauma 2025. link 9 Ahn L, Christensen JM, Fruge S, Meulendijks MZ, Hoftiezer YAJ, Wong FK et al.. Preoperative Vascular Imaging in Lower Extremity Free Flap Reconstruction: Comparison Between Imaging Modalities. Microsurgery 2024. link 10 Pereira N, Venegas J, Oñate V, Camacho JP, Roa R. Extremity reconstruction with superficial circumflex iliac artery perforator free flap: Refinements and innovations after 101 cases. Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2023. link 11 Morii H, Inui T, Shibayama H, Oae K, Onishi F, Hashimoto T et al.. Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries. Injury 2023. link 12 Ammar HM, Kim J, Lee KT. Usefulness of indocyanine green angiography in the intraoperative evaluation of recipient vessels for microsurgical lower extremity reconstruction in ischemic vasculopathy: Report of three cases. Microsurgery 2023. link 13 Wong FK, Christensen JM, Meulendijks MZ, Iskhakov D, Ahn L, Fruge S et al.. Secondary Surgery after Lower Extremity Free Flap Reconstruction. Plastic and reconstructive surgery 2023. link 14 Kim C, Baker D, Albers B, Kaar SG. An Anatomically Placed Tibial Tunnel does not Completely Surround a Simulated PCL Reconstruction Graft in the Proximal Tibia. The journal of knee surgery 2023. link 15 Theile H, Wiper J, Noblet T, Watson L, Wagels M. Microsurgical anastomosis using anterior versus posterior tibial artery in lower limb free tissue transfer. ANZ journal of surgery 2022. link 16 Wallace AB, Kim EA, Holland M, Lee S, Orringer M, Piper ML et al.. Diagnosis and Treatment of Lymphatic Complications of the Groin Following Open Lower Extremity Revascularization with Plastic Surgery Closure. Annals of vascular surgery 2022. link 17 Song P, Pu LLQ. Perforator-Plus Flaps in Lower Extremity Reconstruction. Clinics in plastic surgery 2021. link 18 Xu L, Tan J, Qin H, Mo Y, Wei P, Luo X et al.. Application of computed tomography angiography-assisted classification of arterial branches in the first web space of the foot for thumb reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2021. link 19 Teo TC. Propeller Flaps for Reconstruction around the Foot and Ankle. Journal of reconstructive microsurgery 2021. link 20 Crowley JD, Hosgood G, Appelgrein C. Seed skin grafts for reconstruction of distal limb defects in 15 dogs. The Journal of small animal practice 2020. link 21 Karir A, Stein MJ, Shiga S, Zhang J. Reconstruction of Lower Extremity Defects Using the Serratus Anterior Free Flap: A Systematic Review and Retrospective Case Series. Journal of reconstructive microsurgery 2020. link 22 Koh K, Goh TLH, Song CT, Suh HS, Rovito PV, Hong JP et al.. Free versus Pedicled Perforator Flaps for Lower Extremity Reconstruction: A Multicenter Comparison of Institutional Practices and Outcomes. Journal of reconstructive microsurgery 2018. link 23 A Magnussen R, Binzel K, Zhang J, Wei W, U Knopp M, C Flanigan D et al.. ACL graft metabolic activity assessed by . The Knee 2017. link 24 Ahmed F, Grade M, Malm C, Michelen S, Ahmed N. Surgical volunteerism or voluntourism - Are we doing more harm than good?. International journal of surgery (London, England) 2017. link 25 Ambrosia J, Qazi Z, Shuler FD, Giangarra C. Delayed Pseudoaneurysm of the Popliteal Artery Following ACL Reconstruction. Orthopedics 2015. link 26 Santanelli di Pompeo F, Pugliese P, Sorotos M, Rubino C, Paolini G. Microvascular reconstruction of complex foot defects, a new anatomo-functional classification. Injury 2015. link 27 Hensler D, Illingworth KD, Musahl V, Working ZM, Kobayashi T, Miyawaki M et al.. Does fibrin clot really enhance graft healing after double-bundle ACL reconstruction in a caprine model?. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2015. link 28 Andrei R, Popescu SA, Zamfirescu D. Lower limb perforator propeller flaps - clinical applications. Chirurgia (Bucharest, Romania : 1990) 2014. link 29 Muller B, Bowman KF, Bedi A. ACL graft healing and biologics. Clinics in sports medicine 2013. link 30 Abdel Karim MM, Anbar A, Keenan J. Position of the popliteal artery in revision total knee arthroplasty. Archives of orthopaedic and trauma surgery 2012. link 31 Sandoval E, Ortega FJ, García-Rayo MR, Resines C. Popliteal pseudoaneurysm after total knee arthroplasty secondary to intraoperative arterial injury with a surgical pin: review of the literature. The Journal of arthroplasty 2008. link 32 Teles G, Bastos V, Mello G. Correction of hypercromic palmar graft with split-thickness instep plantar graft: case report. Journal of burn care & research : official publication of the American Burn Association 2008. link 33 Lo CH, Leung M, Leong J. Inferior vena cava filters and lower limb flap reconstructions. ANZ journal of surgery 2008. link 34 Keene JS, Davis RA. Technique to facilitate graft passage in posterolateral reconstructions of the knee. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2005. link 35 Oien RF, Håkansson A, Hansen BU, Bjellerup M. Pinch grafting of chronic leg ulcers in primary care: fourteen years' experience. Acta dermato-venereologica 2002. link 36 Dini M, Innocenti A, Russo GL, Agostini V. The use of the V-Y fasciocutaneous island advancement flap in reconstructing postsurgical defects of the leg. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2001. link 37 Feibel RJ, Oliva A, Buncke GM, Jackson RL, Buncke HJ. Soft-tissue reconstruction in orthopedic surgery. Secondary procedures. The Orthopedic clinics of North America 1993. link 38 Forrest C, Boyd B, Manktelow R, Zuker R, Bowen V. The free vascularised iliac crest tissue transfer: donor site complications associated with eighty-two cases. British journal of plastic surgery 1992. link90163-r) 39 Hong G, Steffens K, Wang FB. Reconstruction of the lower leg and foot with the reverse pedicled posterior tibial fasciocutaneous flap. British journal of plastic surgery 1989. link90035-0) 40 Yaremchuk MJ, Sedacca T, Schiller AL, May JW. Vascular knee allograft transplantation in a rabbit model. Plastic and reconstructive surgery 1983. link

    Original source

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      Superficial Circumflex Iliac Artery Perforator Flap with Bilobed Design for the Donor Defect after Wrap-Around Flap Transfer Reconstruction. — Hu C, Hou B, Huang X, Xu Y, He Q, Song J et al. Orthopaedic surgery (2023)
    2. [2]
      Surgical Reconstruction of Complex Distal Foot Defects With Vascularized Fascia Lata. — Liu M, Yang Y, Zhang Y, Yang X, Hu D Annals of plastic surgery (2020)
    3. [3]
      Evaluation of a genicular axial pattern flap to repair large cutaneous tibial defects in two dogs. — Ober C, Milgram J, McCartney W, Taulescu M, Pestean C, Melega I et al. BMC veterinary research (2019)
    4. [4]
      Subcutaneous administration of a neutralizing IL-1β antibody prolongs limb allograft survival. — Hautz T, Grahammer J, Moser D, Eberhart N, Zelger B, Zelger B et al. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons (2018)
    5. [5]
      Injury to the Anterior Tibial Artery during Bicortical Tibial Drilling in Anterior Cruciate Ligament Reconstruction. — Kim SB, Lim JW, Seo JG, Ha JK Clinics in orthopedic surgery (2016)
    6. [6]
      Engendering allograft ignorance in a mouse model of allogeneic skin transplantation to the distal hind limb. — Agarwal S, Loder S, Wood S, Cederna PS, Bishop DK, Wang SC et al. Annals of surgery (2015)
    7. [7]
      Combined Use of a Pedicled Medial Sural Artery Perforator Flap and a V-Y Advancement Flap Based on an Anterior Tibial Artery Perforator for Pretibial Defect Reconstruction: A Case Report. — Martini F, Meroni M, Scaglioni MF Microsurgery (2026)
    8. [8]
      Medial-Based Myofasciocutaneous Flap Above Knee Amputation. — Wu WW, Finkemeier C Journal of orthopaedic trauma (2025)
    9. [9]
      Preoperative Vascular Imaging in Lower Extremity Free Flap Reconstruction: Comparison Between Imaging Modalities. — Ahn L, Christensen JM, Fruge S, Meulendijks MZ, Hoftiezer YAJ, Wong FK et al. Microsurgery (2024)
    10. [10]
      Extremity reconstruction with superficial circumflex iliac artery perforator free flap: Refinements and innovations after 101 cases. — Pereira N, Venegas J, Oñate V, Camacho JP, Roa R Journal of plastic, reconstructive & aesthetic surgery : JPRAS (2023)
    11. [11]
      Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries. — Morii H, Inui T, Shibayama H, Oae K, Onishi F, Hashimoto T et al. Injury (2023)
    12. [12]
      Usefulness of indocyanine green angiography in the intraoperative evaluation of recipient vessels for microsurgical lower extremity reconstruction in ischemic vasculopathy: Report of three cases. — Ammar HM, Kim J, Lee KT Microsurgery (2023)
    13. [13]
      Secondary Surgery after Lower Extremity Free Flap Reconstruction. — Wong FK, Christensen JM, Meulendijks MZ, Iskhakov D, Ahn L, Fruge S et al. Plastic and reconstructive surgery (2023)
    14. [14]
      An Anatomically Placed Tibial Tunnel does not Completely Surround a Simulated PCL Reconstruction Graft in the Proximal Tibia. — Kim C, Baker D, Albers B, Kaar SG The journal of knee surgery (2023)
    15. [15]
      Microsurgical anastomosis using anterior versus posterior tibial artery in lower limb free tissue transfer. — Theile H, Wiper J, Noblet T, Watson L, Wagels M ANZ journal of surgery (2022)
    16. [16]
      Diagnosis and Treatment of Lymphatic Complications of the Groin Following Open Lower Extremity Revascularization with Plastic Surgery Closure. — Wallace AB, Kim EA, Holland M, Lee S, Orringer M, Piper ML et al. Annals of vascular surgery (2022)
    17. [17]
      Perforator-Plus Flaps in Lower Extremity Reconstruction. — Song P, Pu LLQ Clinics in plastic surgery (2021)
    18. [18]
      Application of computed tomography angiography-assisted classification of arterial branches in the first web space of the foot for thumb reconstruction. — Xu L, Tan J, Qin H, Mo Y, Wei P, Luo X et al. Journal of plastic, reconstructive & aesthetic surgery : JPRAS (2021)
    19. [19]
      Propeller Flaps for Reconstruction around the Foot and Ankle. — Teo TC Journal of reconstructive microsurgery (2021)
    20. [20]
      Seed skin grafts for reconstruction of distal limb defects in 15 dogs. — Crowley JD, Hosgood G, Appelgrein C The Journal of small animal practice (2020)
    21. [21]
      Reconstruction of Lower Extremity Defects Using the Serratus Anterior Free Flap: A Systematic Review and Retrospective Case Series. — Karir A, Stein MJ, Shiga S, Zhang J Journal of reconstructive microsurgery (2020)
    22. [22]
      Free versus Pedicled Perforator Flaps for Lower Extremity Reconstruction: A Multicenter Comparison of Institutional Practices and Outcomes. — Koh K, Goh TLH, Song CT, Suh HS, Rovito PV, Hong JP et al. Journal of reconstructive microsurgery (2018)
    23. [23]
      ACL graft metabolic activity assessed by — A Magnussen R, Binzel K, Zhang J, Wei W, U Knopp M, C Flanigan D et al. The Knee (2017)
    24. [24]
      Surgical volunteerism or voluntourism - Are we doing more harm than good? — Ahmed F, Grade M, Malm C, Michelen S, Ahmed N International journal of surgery (London, England) (2017)
    25. [25]
      Delayed Pseudoaneurysm of the Popliteal Artery Following ACL Reconstruction. — Ambrosia J, Qazi Z, Shuler FD, Giangarra C Orthopedics (2015)
    26. [26]
      Microvascular reconstruction of complex foot defects, a new anatomo-functional classification. — Santanelli di Pompeo F, Pugliese P, Sorotos M, Rubino C, Paolini G Injury (2015)
    27. [27]
      Does fibrin clot really enhance graft healing after double-bundle ACL reconstruction in a caprine model? — Hensler D, Illingworth KD, Musahl V, Working ZM, Kobayashi T, Miyawaki M et al. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA (2015)
    28. [28]
      Lower limb perforator propeller flaps - clinical applications. — Andrei R, Popescu SA, Zamfirescu D Chirurgia (Bucharest, Romania : 1990) (2014)
    29. [29]
      ACL graft healing and biologics. — Muller B, Bowman KF, Bedi A Clinics in sports medicine (2013)
    30. [30]
      Position of the popliteal artery in revision total knee arthroplasty. — Abdel Karim MM, Anbar A, Keenan J Archives of orthopaedic and trauma surgery (2012)
    31. [31]
      Popliteal pseudoaneurysm after total knee arthroplasty secondary to intraoperative arterial injury with a surgical pin: review of the literature. — Sandoval E, Ortega FJ, García-Rayo MR, Resines C The Journal of arthroplasty (2008)
    32. [32]
      Correction of hypercromic palmar graft with split-thickness instep plantar graft: case report. — Teles G, Bastos V, Mello G Journal of burn care & research : official publication of the American Burn Association (2008)
    33. [33]
      Inferior vena cava filters and lower limb flap reconstructions. — Lo CH, Leung M, Leong J ANZ journal of surgery (2008)
    34. [34]
      Technique to facilitate graft passage in posterolateral reconstructions of the knee. — Keene JS, Davis RA Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association (2005)
    35. [35]
      Pinch grafting of chronic leg ulcers in primary care: fourteen years' experience. — Oien RF, Håkansson A, Hansen BU, Bjellerup M Acta dermato-venereologica (2002)
    36. [36]
      The use of the V-Y fasciocutaneous island advancement flap in reconstructing postsurgical defects of the leg. — Dini M, Innocenti A, Russo GL, Agostini V Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] (2001)
    37. [37]
      Soft-tissue reconstruction in orthopedic surgery. Secondary procedures. — Feibel RJ, Oliva A, Buncke GM, Jackson RL, Buncke HJ The Orthopedic clinics of North America (1993)
    38. [38]
      The free vascularised iliac crest tissue transfer: donor site complications associated with eighty-two cases. — Forrest C, Boyd B, Manktelow R, Zuker R, Bowen V British journal of plastic surgery (1992)
    39. [39]
      Reconstruction of the lower leg and foot with the reverse pedicled posterior tibial fasciocutaneous flap. — Hong G, Steffens K, Wang FB British journal of plastic surgery (1989)
    40. [40]
      Vascular knee allograft transplantation in a rabbit model. — Yaremchuk MJ, Sedacca T, Schiller AL, May JW Plastic and reconstructive surgery (1983)

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